The recent release of the Department of Justice’s annual report on its Health Care Fraud and Abuse Control Program made it clear that the federal government continues to focus on this area of criminal law. It has shown time and again that it is willing to charge doctors, pharmacists, executives and investors alike.
Healthcare fraud allegations can be leveled against both government payers and private payers, according to a recent news article.
The article cited the example of seven people who were accused of involvement in a bribery scheme that purportedly revolved around a doctor-owned surgical center. The DOJ alleged that the scheme involved hospital executives and other employees, such as doctors and marketing executives.
The surgical center was to cater to high-paying patients who were self-funded or privately insured while transferring patients enrolled in lower-paying health care plans offered by the federal government to other hospitals for fees. The high-paying individuals were treated as “out of network” patients, the news article stated.
Some of the criminal claims involved patients covered by TRICARE and FECA (the Federal Employee Compensation Act), but most indictments were related to actions taken by defendants related to private insurance. The government said defendants waived co-pay requirements for those high-paying, privately insured patients so that their personal outlays would be the same as if they were “in network,” while the defendants billed the insurers at “out of network” rates.
The lower-paying patients (often covered by Medicare and Medicaid) were referred to other health care facilities for cash.
Chicago-area physicians and others in the healthcare industry who are under investigation for purported healthcare fraud should decline to speak to investigators until after they have contacted an attorney experienced in this complicated area of law.